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CASE REPORT  
Year : 2015  |  Volume : 58  |  Issue : 3  |  Page : 389-391
Cervical strongyloidiasis in an immunocompetent patient: A clinical surprise


1 Department of Oncopathology, AHRCC, Cuttack, Odisha, India
2 Department and Pathology, SCB Medical College, Cuttack, Odisha, India

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Date of Web Publication14-Aug-2015
 

   Abstract 

A 32-year-old lady came for a routine gynecological check up. Her cervical cytologic smear was reported as low grade squamous intraepithelial lesion. As a part of basic routine investigation, cervical punch biopsy was done. Astonishingly it revealed multiple rhabditiform larvae of Strongyloides stercoralis. These were curved thick with pointed end and a short buccal cavity. She did not have any history of immunosuppression including steroid therapy and was otherwise normal. Extensive review of the literature on parasites encountered in cervix yielded few case reports on strongyloides in cytologic smears, but failed to reveal any report till date on S. stercoralis found in histopathology section. Our case is probably the first in the world and the first reported from India to the best of our knowledge. We describe this case of strongyloidiasis of cervix with review of the literature on various parasites encountered in the cervix because of its rarity and also to keep this parasitic infestation as a differential diagnosis of cervical lesions.

Keywords: Cervix, histopathology, immunocompetent, strongyloides stercoralis

How to cite this article:
Panda S, Kar A, Das U, Rout N. Cervical strongyloidiasis in an immunocompetent patient: A clinical surprise. Indian J Pathol Microbiol 2015;58:389-91

How to cite this URL:
Panda S, Kar A, Das U, Rout N. Cervical strongyloidiasis in an immunocompetent patient: A clinical surprise. Indian J Pathol Microbiol [serial online] 2015 [cited 2020 Jun 6];58:389-91. Available from: http://www.ijpmonline.org/text.asp?2015/58/3/389/162927



   Introduction Top


Strongyloidiasis caused by the nematode Strongyloides stercoralis infection is a neglected condition and usually asymptomatic or may present with intermittent symptoms. [1] Though trivial it can be severe and fatal in immunosuppressed individuals and present with gastrointestinal, pulmonary and cutaneous manifestations who may develop disseminated strongyloidiasis or hyperinfection syndrome by the worm. [2] Therefore, it is crucial to diagnose and treat the chronic infection, and hence that the life-threatening forms and risks there from can be prevented. Unfortunately, the index of suspicion of this infestation by the health care providers seems to be low, especially in nonendemic countries. Therefore, we describe a case of cervical strongyloidiasis, which was diagnosed incidentally to sensitize the pathologists about such a situation, which can be considered in the differential diagnosis of cervical pseudocarcinomatous lesions though encountered infrequently.


   Case Report Top


A 32-year-old female had complaint of leucorrhoea and backache. She was from the nearby village and of low socioeconomic status. She had two living children of 9 and 6 years old and had completed her family. During the routine gynecological check-up, her cervical smear was collected, and a diagnosis of low grade squamous intraepithelial lesion (LSIL) was rendered. Colposcopic examination showed flat, ill-defined acetowhite shiny area in the cervix. We received the cervical punch biopsy from the affected area, which detected curved, rhabditiform larval stage of S. stercoralis with pointed end beneath the stratified squamous epithelium along with intense infiltration by acute and chronic inflammatory cells [Figure 1] and [Figure 2]. The squamous cells show mild enlargement of nuclei with high nuclear: Cytoplasmic (N:C) ratio [Figure 1]. Later on retrogradely, we observed peripheral eosinophilia of 18%. Her chest X-ray did not reveal any abnormalities. She gave a history of irregular bowel habits with intermittent diarrhea. Unfortunately, the stool examination did not reveal the larva of strongyloides. The patient was treated with ivermectin, and she is doing well till now.
Figure 1: Cervical biopsy with multiple larvae of strongyloides with nuclear enlargement and mild atypia in squamous epithelium (H and E, ×400) (arrow points to larvae)


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Figure 2: (a-d) Different foci from the section showing multiple curved and pointed larvae of Strongyloides stercoralis (H and E)


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   Discussion Top


Strongyloidiasis, a chronic parasitic infection of humans, is frequently underdiagnosed because many patients are asymptomatic and moreover, the diagnostic methods lack sensitivity. It is a peculiar parasite with a complex life cycle capable of auto-infection. In cases of immunodeficiency, it can be severe and life threatening. The infection does not resolve without appropriate therapy and can persist for life. Due to its minimal symptoms it may go unnoticed many times, and one should be aware of its presence so that it can be treated early, and serious situations can be avoided.

Strongyloides is found more frequently in the socioeconomically low, in institutionalized populations, and in rural areas particularly associated with agricultural activities and risk factors like a warm temperature and poor sanitation. Though it is an intestinal nematode, extraintestinal infections occur in the lungs, liver, spleen, pancreas, gall bladder, kidneys, thyroid, brain and meninges, skin, mesenteric lymph nodes, ovaries and skeletal muscle in hyperinfection. [3],[4] In the case of hyperinfection and disseminated strongyloidiasis, larvae can also be found in other samples such as sputum, duodenal aspirates, gastric biopsies, cervical smear or cerebrospinal fluid.

In spite of its wide prevalence, its occurrence in cervix is not reported often. We have got only five previously reported case reports of S. stercoralis in cervicovaginal smears. [5] In each of these case reports, a single rhabditiform larva was identified, against an inflammatory or a relatively clean background. In the present case, we detected multiple rhabditiform larvae in histopathology section, which could be the first case report of strongyloides in cervical biopsy to the best of our knowledge.

In immunodefiecient patients, the infective larvae may re-enter into the duodenum either internally or externally through the penetration in perianal and perineal skin. However, the above patient is not immunocompromised. Her HIV/HBS status were normal. The patient was neither suffering from any pulmonary nor cutaneous manifestations. She belonged to a low socio-economic status, which made her prone to the infection. In present case, the larva might have passed through the perianal skin and reached up to the cervix.

Though fecal examination is the gold standard investigation to diagnose the larval stage or eggs of strongyloides, its sensitivity is very low in case of chronic asymptomatic individuals as the larval excretion is only intermittent. In many intestinal parasitic infestations, though peripheral eosinophilia is the most common finding, it is only transient. Baaten et al. revealed that for intestinal parasitic infection, eosinophilia carries very low positive predictive value (15%). [6] However in case of strongyloidiasis, eosinophilia is more specific and can be considered as a useful screening method particularly in asymptomatic individuals. Therefore, all unexplained hypereosinophilia cases should be evaluated properly.

Reactive or reparative atypia is common in case of heavy inflammation due to parasitic infiltration into the skin, which indicates the treatment for dysplasia, as seen in the present case in cervical cytosmear. Even in histopathology, the squamous epithelial cells are large with mild atypia and high N:C ratio, which can explain the cytologic findings of LSIL [Figure 1].However, the features like loss of polarity, mitosis and nuclear membrane irregularity are absent. Histological examinations can confirm the diagnosis showing sections of larvae, eggs and some adult forms. Larva is characterized by eosinophilic cuticle, oral cavity, long, slim cylindrical body and notched tail. Filariform larvae are longer, thinner and have a long oral cavity.However, rhabditiform larvae are thick, curved and with a short oral cavity and muscular (rhabditiform) esophagus. These can be confused with larvae of hookworm, which can be distinguished due to long buccal cavity (approximately three times as long). Other parasites encountered in cervix can be entamoeba histolytica, paragonimus westermani, schistosoma and microfilaria, but these can be distinguished by the classical morphology of strongyloides.

Though thiabendazole was given earlier, recently ivermectin is the treatment of choice. Above said patient was treated by ivermectin and is doing well.

Finally, the authors conclude that to treat and eradicate strongyloidiasis, the health workers must be familiar with S. stercoralis and should keep it as a differential diagnosis in any case of hypereosinophilia in patients from low socioeconomic status or endemic areas.

 
   References Top

1.
Murty DA, Luthra UK, Sehgal K, Sodhani P. Cytologic detection of Strongyloides stercoralis in a routine cervicovaginal smear. A case report. Acta Cytol 1994;38:223-5.  Back to cited text no. 1
    
2.
Bogitsh BJ, Carter CE. Strongyloides stercoralis. Human Parasitology. 4 th ed. Academic Press: Philadelphia, Elsevier; 2013. p. 301-6.  Back to cited text no. 2
    
3.
Kim J, Joo HS, Kim DH, Lim H, Kang YH, Kim MS. A case of gastric strongyloidiasis in a Korean patient. Korean J Parasitol 2003;41:63-7.  Back to cited text no. 3
    
4.
Maguire WF, Mintzer DM, Stopyra GA, Stern J. Strongyloidiasis diagnosed by endoscopic biopsy in a patient with multiple myeloma. Commun Oncol 2006;3:144-6.  Back to cited text no. 4
    
5.
Mayekar V, Ruben I, Rekhi B. Serendipitously identified Strongyloides stercoralis in a cervicovaginal smear. J Cytol 2013;30:270-1.  Back to cited text no. 5
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6.
Baaten GG, Sonder GJ, van Gool T, Kint JA, van den Hoek A. Travel-related schistosomiasis, strongyloidiasis, filariasis, and toxocariasis: The risk of infection and the diagnostic relevance of blood eosinophilia. BMC Infect Dis 2011;11:84.  Back to cited text no. 6
    

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Correspondence Address:
Dr. Asaranti Kar
SCB Medical College, SCB Medical Campus, Qrs. No. JO-1, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.162927

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